Delhi Journal of Ophthalmology

Hemorrhagic Retinal Detachment Following Severe Dengue Fever - A Case Report

Abhishek Varshney1, Manmath Das2
1CL Gupta Eye Institute, Moradabad, Uttar Pradesh India; 2KIIT Campus, Bhubaneshwar, Odisha, India

Corresponding Author:

Abhishek Varshney 
MS
Consultant, Vitreoretina
C L Gupta Eye Institute, Ram Ganga Vihar 
Phase 2 (Ext.) Moradabad - 244001
Uttar Pradesh, India
Email id: doctorabhishekvarshney@gmail.com

Published Online: 31-JAN-2019

DOI:http://dx.doi.org/10.7869/djo.419

Abstract
A child suffering from dengue haemorrhagic fever, diagnosed elsewhere, reported to our hospital with complaints of sudden painless loss of vision in both eyes for 2 days. Ocular examination revealed profound visual impairment in both eyes, quiet anterior segment, vitreous haemorrhage and retinal detachment. Ultrasonography revealed haemorrhagic retinal detachment in both the eyes. Blood counts showed severe anaemia with thrombocytopenia. Considering the urgency of the systemic condition, he was referred to a multi-speciality hospital and was asked to review at the hospital when systemic parameters become stable. He did not return for follow up and expired a few months later.

Keywords :Anaemia, Massive subretinal haemorrhage, Ocular ultrasonography, Severe dengue fever, Thrombocytopenia

Dengue fever is one of the most common mosquito borne disease in the tropics. Sudden onset fever with malaise, signs of upper respiratory tract infection, severe cephalegia, myalgia, retro-orbital pain, lumbosacral pain, and papules are the characteristic features of dengue infection. In India, the prevalence of ophthalmic features of dengue in ophthalmic patients ranges from 16% to 40.3%.1,2 Reported anterior segment signs are subconjunctival hemorrhage, keratitis, corneal erosion, acute angle closure, anterior uveitis, and intermediate uveitis. Posterior segment signs include retinal haemorrhages, posterior uveitis, foveolitis, maculopathy, retinal vascular occlusions, and serous retinal detachment. Neuro-ophthalmic disorders include optic neuritis, cranial nerve palsies, and neuromyelitis optica. Panophthalmitis, periorbital ecchymosis, and other haemorrhagic complications may also occur.3 Seet et al speculated that the risk factors for development of ocular symptoms are decreased white blood cell count and hypoalbuminemia.4 The ocular manifestations usually resolve as the platelet counts improve. Steroids are given in the cases of active inflammation either topically, orally, intravitreally or intravenously.3

Case Report 
A 14 year old febrile and pale looking male child reported to our institute with history of sudden painless loss of vision for 2 days in both eyes. He also gave history of fever for 25 days and bleeding per rectum 7 days after onset of fever. Review of his old records showed that he has been diagnosed as a case of dengue elsewhere (qualitative IgG ELISA and NS1 antigen were positive). His visual acuity was finger counting close to face not improving with glasses. Intra ocular pressure was 14 mm of Hg by Goldmann Applanation Tonometer. Both pupils were mid-dilated and sluggishly reacting to light. Fundus examination of both eyes showed vitreous haemorrhage, subretinal haemorrhage and retinal detachment (Figure 1). Ultrasound of both the eyes was performed and showed moderate number of low to moderately reflective vitreous echoes, a high reflective membrane echo attached to the disc with poor after movements and persisting in low gain suggesting retinal detachment. Plenty of sub-retinal, mobile, moderately reflective dot echoes were noted which were layered in the  sub-retinal space signifying sub-retinal haemorrhage (Figure 2). An urgent physician opinion was advised and blood counts were carried out. His temperature (oral) was 102°F. The haemoglobin was 5.3 gm%, total leucocyte count was 7910 cells/mm3, differential leucocyte count was within normal limits, and platelets were 9000 cells/mm3. General blood picture revealed hypochromic and microcytic red blood corpuscles with normal leucocytes and inadequate platelets. Considering the general condition of the patient he was urgently referred to a multi-specialty hospital for management of his systemic ailment. He was asked to review when his systemic parameters were normal. As the patient did not turn up for follow-up even after 6 months, a telephonic call was made which revealed that the patient was deceased.


Discussion
Severe dengue fever is defined by at least one of the following: severe bleeding, severe organ impairment, or plasma leakage.5 The disease spectrum of dengue eye disease can be either unilateral or bilateral. Most ocular symptoms have been noted approximately 7 days of onset of fever. This usually coincides with the nadir of thrombocytopenia.6
Listed anterior segment signs are subconjunctival hemorrhage, keratitis, corneal erosion, acute angle closure, anterior uveitis, and intermediate uveitis. Posterior segment signs include vitreous haemorrhage, intraretinal and subretinal haemorrhages, posterior uveitis, foveolitis, maculopathy, retinal vascular occlusions, and serous retinal detachment. Neuro-ophthalmic disorders include optic neuritis, cranial nerve palsies, and neuromyelitisoptica. Panophthalmitis, periorbital ecchymosis, and other hemorrhagic complications may also occur.3 In a study of 156 patients, Seet et al reported leucopenia and hypoalbuminemia as the risk factors for development of ocular manifestations.4 Most of the manifestations are benign and self-resolving as platelet counts come back to normal but few dreaded complications like auto evisceration has also 
been reported.7
Close observation is the usual treatment. As thrombocytopenia resolves, ocular signs show improvement.2,6,8 Steroids have been used in various delivery modes depending upon the ocular pathology with varying results and duration of treatment. Topical route is generally preferred for anterior uveitis, whereas systemic corticosteroids are preferred for patients with maculopathy, vasculitis, posterior uveitis, optic nerve complications and exudative retinal detachments.3
Though intraretinal and subretinal hemorrhages have been reported in the literature, massive subretinal hemorrhages so as to cause hemorrhagic retinal detachment has not been reported. To the best of our knowledge, haemorrhagic retinal detachment along with severe dengue fever has not been reported in ophthalmic literature.

References
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  2. Kapoor HK, Bhai S, John M, Xavier J. Ocular manifestations of dengue fever in an East Indian epidemic. Can J Ophthalmol 2006; 41:741-6.
  3. Ng AW, Teoh SC. Dengue eye disease. Surv Ophthalmol 2015; 60:106-114.
  4. Seet RC, Quek AM, Lim EC. Symptoms and risk factors of ocular complications following dengue infection. J Clin Virol 2007; 38:101-5.
  5. Nathan MB, Dayal-Drager R, Guzman M. Epidemiology, burden of disease and transmission, in WHO: Dengue Guidelines for Diagnosis, Treatment, Prevention and Control. Geneva, WHO; new edition 2009, pp 1e21.
  6. Chan DP, Teoh SC, Tan CS, Nah GK, Rajagopalan R, Prabhakargupta MK, et al. Ophthalmic complications of dengue. Emerg Infect Dis 2006;12:285-9.
  7. Nagaraj KB, Jaydev C, Yajmaan S, Prakash S. An unusual ocular emergency in severe dengue. Middle East Afr J Ophthalmol 2014; 21:347-349.
  8. Bacsal KE, Chee SP, Cheng CL, Flores JV. Dengue-associated maculopathy. Arch Ophthalmol 2007; 125:501–510.

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Abhishek Varshney, Manmath DasHemorrhagic Retinal Detachment Following Severe Dengue Fever - A Case Report.DJO 2019;29:52-53

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Abhishek Varshney, Manmath DasHemorrhagic Retinal Detachment Following Severe Dengue Fever - A Case Report.DJO [serial online] 2019[cited 2019 Apr 22];29:52-53. Available from: http://www.djo.org.in/articles/29/3/Hemorrhagic-Retinal-Detachment-Following-Severe-Dengue-Fever.html